Susanne Astrab Fogger, DNP, PMNHPPMNHP-BC School of Nursing University of Alabama at Birmingham. do we expect?

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1 Susanne Astrab Fogger, DNP, PMNHPPMNHP-BC School of Nursing University of Alabama at Birmingham What do we expect?

2 1. Total long term abstinence 2. Risk reduction Methods to re-enforce enforce continued abstinence Medications augment other treatments May reduce or delay urges to use

3 Effect neurotransmitters by reestablishing hemostasis Interfere with reinforcing effects and drug binging Reducing drug induced dopamine release Reducing postsynaptic dopamine responses Decrease delivery to the brain Compensate for the adaptations that either predated or developed after long- term use 1. Decrease prioritized motivational value of the drug 2. Enhance the saliency value of natural reinforcers 3. Interfere with conditioned responses, stress induced relapse or physical withdrawal

4 Continued drug use aversion Block euphoric effect Reduce drug craving Frequently the cost of the treatment is believed to be prohibitive Some see use of medications as a crutch and not helpful to recovery Medications do not have 100% effectiveness for everyone

5 Naltrexone Acamprosate Disulfiram *Topiramate* (Category C) (Category C) (Category C) (Category D)

6 Prevents the liver from metabolizing alcohol normally Causes a toxic breakdown product to accumulate. Inhibits the enzyme aldehyde dehydrogenase Converts acetaldehyde to acetate Nauseated, vomiting Facial flushing Headache Palpitations Hypotension Chest pain

7 . Disulfiram Usual dose: 250 mg daily (range ) Contraindications: use of alcohol, alcohol-containing substances or metronidazole; coronary artery disease Serious adverse reactions: disulfiram-alcohol reaction; hepatitis; optic neuritis; peripheral neuropathy; psychotic reactions Common side effects: metallic aftertaste; dermatitis; transient mild drowsiness Patient recommended to carry card identifying they are on ANTABUSE

8 Used widely throughout the world since the 1980 s Approved in USA by FDA in Lowers the activity of receptors for the excitatory neurotransmitter glutamate- May work best for: Anxiety Physiological dependence Negative family hx of alcohol use disorder Late age of onset (age>25) Female gender Consider if: patients do not respond to naltrexone naltrexone contraindicated

9 Abstinence rates 2-3X greater in patients taking acamprosate than those taking a placebo NNT 20 Two-333mg tabs -666mg TID Price - about $ 100 per month Stimulates the inhibitory neurotransmitter gamma amino butyric acid (GABA) Like Acamprosate reduces the activity of glutamate May slow release of dopamine in the brain s reward system Increases days abstinence and alleviates cravings

10 Dosage: 25mg/day increase by 25-50mg per day at weekly intervals target of 300mg/day in divided doses Slow titration needed to prevent side effects Excreted through kidney-rare metabolic acidosis nephrolithiasis Monitor serum bicarbonate & renal functions Off Label use Helps to decrease craving of alcohol Decreases number of drinks per week Risks Risk of metabolic acidosis Decreased serum bicarb levels Cognitive adverse affects

11 Dizziness Tingling in the hands and feet Weight loss Temporary loss of memory Difficulty concentrating Lowers the activity of natural opioids reduces the euphoric effect of alcohol in some alcoholics Reduces the desire to drink and especially craving that leads to relapse after a first drink Now comes in PO or IM form NNT-12

12 Opioid use must be stopped at least 7 days prior to starting naltrexone Assess pregnancy status Blocks pain relief from opiate medications Does not reduce effectiveness of local and general anesthesia Non-narcotic pain relievers can be utilized When taking naltrexone patients should inform health care providers - possible interactions with other medications can be evaluated Dosage: Oral: mg daily IM: 380 mg monthly Side effects: Nausea Headache Depression Dizziness Fatigue Insomnia Anxiety Sleepiness

13 Reduced the risk of relapse Return to heavy drinking in first three months by 36% The effect does not persist when patients stop taking the drug. Superior to placebo only when took % of medications 70 90% of medications Should opiates be necessary to treat the client on depot -Can reverse the opioid blockade with high doses of opioids IF anticipating surgery stop the po medication 5-7 days before-

14 Review labs and other markers of chemical use Discuss effects of alcohol on RBC, liver, weight and lipids Look at improving lab as an outcome measure GGT first to go up, last to come down May be elevated in non alcoholic liver disease More sensitive measure in males than females May begin to decrease 2-3 weeks after abstinence

15 Monitoring of liver function tests is recommended for naltrexone & Disulfiram Cr for Acamprosate Cr and bicarb at baseline for Topiramate

16 What makes opiate replacement therapy safer than no treatment? Methadone-long acting full opiate agonist Reduces withdrawal symptoms Reduces opiate craving If dose is high enough, reduces euphoric effect of heroin and oral opiate pain relievers DOC for pregnant women Highly regulated Requires close monitoring High risk for OD

17 Deaths up 390% with OD Attributed to prescription use for pain Less expensive than OxyContin Highly variable half life hours Risk of delayed OD Buprenorphine/naltrexone 4:1 Limited absorption of Naltrexone sublingually Almost complete first pass metabolism limited availability May be safer as it has a ceiling effect in dose increases. Unlikely death from OD Does not diminish testosterone as methadone less sexual impairment with men

18 Partial mu opioid agonist Less abuse potential Qualified MD Combination buprenorphine and naloxone (Suboxone) Blocks effects of buprenorphine if injected Not when used SL Reduces craving Opioid antagonist Mu, kappa & sigma opiate receptors- Auto-injection 0.4mg IV, IM, SQ or intranasally Onset within minutes Lasts 2 hours

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20 Triple dopamine release MAOI 75% occupancy after 3 puffs! Takes 45 minutes to re-sensitize receptor Stopping- increases risk for depression and suicide Varenicline (Chantix) Partial agonist nicotine receptor subtype Reduces nicotine withdrawal symptoms and craving Blocks reinforcing effects of continued nicotine use Nausea main side effect Headache and vivid dreams Behavior changes agitation, depressed mood and suicidal ideation

21 Replacement Replacement- gums, patches, inhalers lozenges and nasal spray Zyban- Dopamine reuptake inhibitor Norepinephrine reuptake inhibitor Antagonist at the nicotine receptors Reduce withdrawal symptoms Reduces reinforcing effects of nicotine Goal is quitting Nicotine patch, gum, tablets, sprays Time limited 8-12 weeks Avoid acidic products like coffee, juice. 30 minutes prior to use

22 Nicotine replacement therapy Increased risk when used while smoking Used where no smoking is permitted

23 Need to get into exercise program when quit Exercise increases dopamine Decreases likelihood of wt gain Ask about psychiatric history No meds currently approved Cocaine dependence-off label Modafinil (provigil) Enhancing glutamate neurotransmission Ameliorate glutamate depletion Blocks euphoric effects mg per day cocaine only, promotes abstinence

24 Personalized medicine- use of genetic information to tailor treatment to patient s genotype Pharmogenetics can determine which medication will have greater response by identifying genetic variants May have better response rates with fewer side effects OPRM1 A118G polymorphism as a moderator of naltrexone response Combination Wellbutrin SR and naltrexone FDA approved for overweight with risk factors and obese Decreases appetite and curbs cravings Approved for those with BMI>27 with risk factors or BMI>30 Nausea most common s/e Cost est- $ per month

25 Medications augment counseling Medications support recovery through Reducing euphoric effect Block drug craving Aversive effects New discoveries in understanding of brain reward system will lead to new medications and treatments of chemical dependencies

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